A nurse assesses an 85-year-old client and finds bruises on the arms and shins and a skin tear on the right hand. Which action is the priority for further nursing assessment?
A) Consider the family as a reliable source of information.
B) Determine if the person is depressed.
C) Follow the protocol for reporting elder abuse.
D) Review the client's medications and medical diagnoses.
Ans: D
The nurse has not yet gathered enough data to determine whether elder abuse is a potential factor. The client/family may not know the source of the bruises, and in fact may provide inaccurate information if they contribute to an abusive situation. It is important to consider adverse medication effects and some medical conditions as potential causes of bruising.
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___ use data to assist staff in modifying or integrating the evidence-based practice change
Fill in the blank with the appropriate word.
A patient with type 2 diabetes mellitus is planning to become pregnant within the next several months. What should the nurse instruct the patient to support the 2020 National Health Goals of reducing the complications of pregnancy from diabetes?
A) Avoid episodes of hyperglycemia. B) Reduce the current exercise regimen by half. C) Limit the intake of carbohydrates and fats in the diet. D) Reduce the use of insulin for blood glucose coverage.
Which response by the nurse is most appropriate when a client asks, "What contraceptive do you think I should use?"
a. "Ask your doctor. She will know what is best for you." b. "The male condom is probably the easiest for you to use." c. "Because you are younger than 40, you should use oral contraceptives." d. "I can discuss the various methods with you so you can decide what is best."
An important reason for using this antacid in renal failure clients is that with prolonged use it leads to phosphate depletion
a. magnesium hydroxide c. sodium bicarbonate b. aluminum hydroxide d. calcium carbonate